The present invention relates generally to methods and apparatus for treating eating disorders by application of modulating electrical signals to a selected cranial nerve, nerve branch or nerve bundle, and more particularly to techniques for treating patients with overeating disorders, and especially obese patients by application of such signals bilaterally to the patient's vagus nerve with one or more neurostimulating devices.
Increasing prevalence of obesity is one of the most serious and widespread health problems facing the world community. It is estimated that currently in American 55% of adults are obese and 20% of teenagers are either obese or significantly overweight. Additionally, 6% of the total population of the United States is morbidly obese. Morbid obesity is defined as having a body mass index of more than forty, or, as is more commonly understood, being more than one hundred pounds overweight for a person of average height. This data is alarming for numerous reasons, not the least of which is it indicates an obesity epidemic. Many health experts believe that obesity is the first or second leading cause of preventable deaths in the United States, with cigarette smoking either just lagging or leading. A recent study from the Kaiser HMO system has demonstrated that morbid obesity drastically increases health care costs (Journal of the American Medical Association (JAMA)).
It is the consequences of being overweight that are most alarming. Obesity is asserted to be the cause of approximately eighty percent of adult onset diabetes in the United States, and of ninety percent of sleep apnea cases. Obesity is also a substantial risk factor for coronary artery disease, stroke, chronic venous abnormalities, numerous orthopedic problems and esophageal reflux disease. More recently, researchers have documented a link between obesity, infertility and miscarriages, as well as post menopausal breast cancer.
Despite these statistics, treatment options for obese people are limited. Classical models combining nutritional counselling with exercise and education have not led to long term success for very many patients. Use of liquid diets and pharmaceutical agents may result in weight loss which, however, is only rarely sustained. Surgical procedures that cause either gastric restriction or malabsorption have been, collectively, the most successful long-term remedy for severe obesity. However, this type of surgery involves a major operation, can lead to emotional problems, and cannot be modified readily as patient needs demand or change. Additionally, even this attempted remedy can sometimes fail (see, e.g., Kriwanek, “Therapeutic failures after gastric bypass operations for morbid obesity,” Langenbecks Archiv. Fur Chirurgie, 38(2): 70-74, 1995).
It is difficult to document many cases of long term success with dietary counselling, exercise therapy and behavioral modification. The introduction of pharmacologic therapy may help improve these results; however, to date pharmacologic remedies have not been able to document long term success. In addition, the chronic use of these drugs can lead to tolerance, as well as side effects from their long term administration. And, when the drug is discontinued, weight returns.
To date, surgical procedures such as gastric bypass or vertical banded gastroplasty have demonstrated the best long term success in treating people with morbid obesity. However, these operations are highly invasive and carry risks of both short and long term complications. Additionally, such operations are difficult to modify, and cannot be regulated up or down if the clinical situation changes.
As a result, a pressing need currently exists for better treatment options for obesity. The long-term failure of liquids and pharmaceuticals aptly demonstrates a need for a life-long control mechanism. A perfect treatment would be adjustable and could be regulated as needed. It would need to be with the patient at all times. The applicants herein are convinced that vagal nerve stimulation has the potential to meet those requirements as a safe and effective treatment for obesity, through an extension of the vagal stimulation technique disclosed in U.S. Pat. No. 5,263,480 to J. Wernicke et al., assigned to the same assignee as the present application. The '480 patent discloses that treatment for eating disorders in general, and obesity and compulsive overeating disorder in particular, may be carried out by selectively applying specially adapted modulating electrical signals to the patient's vagus nerve by a neurostimulator which is preferably totally implanted in the patient, but may alternatively be employed external to the body or even percutaneously. The modulating signals themselves may be stimulating or inhibiting with respect to the electrical activity of the vagus nerve, but for purposes of that patent, both cases were sometimes included within the term “stimulating”. In essence, stimulation of vagal activity could cause more neural impulses to move up the nerve whereas inhibition of vagal activity could block neural impulses from moving up the nerve. The modulating signals can be used to produce excitatory or inhibitory neurotransmitter release.
According to the '480 patent, strategies for vagal modulation, including adjusting the parameters for electrical stimulation of the vagus nerve, nerve fibers or nerve bundle, depend on a number of factors. Among these are considerations of which part(s) of the nerve or the nerve fibers are to be subjected to the modulating signals; whether the patient experiences a “feeling” or sensation at the onset of the disorder or a symptom of the disorder which can be used to activate the neurostimulation generator or, alternatively, a physiologic signal is generated which can be detected and employed to trigger the modulation; and/or whether a “carryover” or refractory period occurs after modulation in which the benefit of the modulation is maintained. Further, for example, appropriate setting of pulse width and amplitude of the stimulating (modulating) signal at the output of the neurostimulator, applied via electrode(s) to the vagus nerve, might allow particular fibers of the nerve to be selectively stimulated. Also, the precise signal pattern to be used, such as the length of the time intervals in which the signal is on and off, might be adjusted to the individual patient and the particular eating disorder being treated.
In treatment of obesity, the '480 patent hypothesized that vagal stimulation could be used to produce appetite suppression by causing the patient to experience satiety, a sensation of “fullness,” which would naturally result in decreased intake of food and consequent weight reduction. In effect, the brain perceives the stomach to be full as a result of the treatment.
In a then-preferred embodiment of the invention disclosed in the '480 patent for treating patients with compulsive overeating/obesity disorders, an implantable neurostimulator included a signal generator or electronics package adapted to generate an electrical output signal in the form of a sequence of pulses, with parameter values programmable by the attending physician within predetermined ranges for treating the disorder, and a lead/electrode system for applying the programmed output signal to the patient's vagus nerve. Calibration of the overall treatment system for a particular patient was to be performed by telemetry by means of an external programmer to and from the implant. The implanted electronics package might be externally programmed for activation upon occurrence of a predetermined detectable event, or, instead might be periodically or continuously activated, to generate the desired output signal with parameter values programmed to treat obesity by modulating vagal activity so as to produce a sensation of satiety.
In alternative embodiments of the invention disclosed in the '480 patent, the stimulus generator or electronics package might be located external to the patient, with only an RF coil, rectifier and the lead/nerve electrode assembly implanted; or with the lead implanted percutaneously through the skin and to the nerve electrode. The latter technique was least preferred because special precautions would be needed to avoid possible infection via the path from outside the body to the nerve along the lead.
In a preferred method of use according to the '480 patent, the stimulus generator of the neurostimulator is implanted in a convenient location in the patient's body, such as in the abdomen in relatively close proximity to the stimulating electrode system and, if applicable, to the detecting system. For treating compulsive overeating and obesity, it might be desirable to ascertain the patient's food intake, i.e., the quantity of food consumed, for example by means of implanted sensing electrodes in or at the esophagus to detect passage of food as the patient swallowed. The swallows could be summed over a preselected time interval to provide an indication or estimate of the amount of food consumed in the selected interval. Modulation of vagal activity would then be initiated if the summation exceeded a predetermined threshold level. In the preferred embodiment of the '480 patent, the stimulating electrode (nerve electrode, e.g., a cuff) would be implanted about the vagus nerve or a branch thereof in the esophageal region slightly above the stomach, and the vagal stimulation applied to produce or induce satiety. As a result, the patient would experience a satisfied feeling of fullness at a level of consumption sufficient to maintain physiologic needs but supportive of weight reduction.
In another method according to the '480 patent, the appropriately programmed output signal of the neurostimulator is applied periodically to modulate the patient's vagus nerve activity, without regard to consumption of a particular quantity of food, except perhaps at prescribed mealtimes during normal waking hours according to the patient's circadian cycle. The intent of such treatment was to suppress the patient's appetite by producing the sensation of satiety between normal mealtimes.
Alternatively, or in addition to either or both of automatic detection of the event and activation of the signal generation in response thereto, or intermittent or sustained activation according to the circadian cycle, the neurostimulator electronics package could be implemented for manual activation of the output signal by the patient, as by placement of an external magnet over the implanted device (to close a switch), or by tapping the region over the device (to cause it to respond to the sound or vibration), or by use of an RF transmitter, for example. Manual activation would be useful in situations where the patient has an earnest desire to control his or her eating behavior, but requires supportive measures because of a lack of sufficient will power or self-control to refrain from the compulsive behavior, such as binge eating or simply overeating, in the absence of the neurostimulation device.